Student blog: Seven weeks in the Solomon Islands

They came in by boat to be seen,
Two adults, a child, and a teen,
Check blood, don’t be lax,
Ah yes, P. vivax,
Give four coartem and two primaquine.

Outpatients

“Small mosquito bite.” My Solomon Island equivalent to the “sharp scratch” used in the UK was a little ironic given that
I would be pricking the finger to test for malaria. With 20% of the population testing positive for malaria each year,
there was a very low index of suspicion for the disease, and most patients who presented would have a blood film made
and examined under the microscope. Certainly everyone with a fever, headache, cold/flu symptoms, or abdominal pain would have malaria ruled out before we considered anything else.

In terms of medical knowledge, I learnt a lot about tropical diseases and their management. I can spot cutaneous Jaws from the door of the waiting room, know all the algorithms for malaria treatment, and can practically make blood films with my
eyes closed. However, I also learnt something else that I wasn’t expecting: how dermatological conditions present on darker skin. I have had very little exposure to that so far in my training, with most of my GP placements occurring in predominantly
white areas. Over the 7 weeks I spent in Gizo, I went from having to ask for help with every skin complaint, to confidently being able to differentiate and manage the full range of rashes and lesions.

In terms of clinical skills, I did many dressings, injections, and making up of drugs. I became much faster and more competent at all of these. I also performed a ring block to remove an ingrown toe nail, sutured wounds, and set up IV infusions. I now feel much more confident performing all of these skills in a time pressured, real world setting. Most of the equipment I used did not differ substantially from the UK, with high levels of sterility preserved and prioritised. Seeing which corners get cut and which don’t when resources are low was interesting.

Finally, my biggest learning point came in terms of the broader skills needed for a doctor. Specifically, I learnt how to make a clinical decision. I know a lot of medical facts, but before my elective, I had never been in the position of being responsible for applying them to a real patient. I realised that when posed with hypothetical questions, I find it easy to say that I favour a more conservative approach (e.g. this patient likely has a viral infection so doesn’t need antibiotics), but faced with a real person who might deteriorate if I decide wrong, I am more reluctant to do this.

During my days in OPD, I was expected to make my own decisions about what I wanted to do with patients, although all of the nurses were happy to answer any of my questions and provide a second opinion when needed. Being faced with this
responsibility was initially terrifying, but as I saw more and more patients, I realised that I did know what to do, and became increasing confident in my own knowledge  and abilities. As a result of limited access to medications or investigations, all of the decisions I was making were fundamentally simple decisions with few options. This meant that I could practice the skill of decision making without the decision itself being too unclear. Decision making training was the most useful thing that I got out of my elective, and I hope will stand me in good stead when I start working.

We were limited in which operations we could perform as Gizo hospital lacks an The surgical team (nurses and doctors) anaesthetist, so all operations happened under one of local anaesthetic, spinal anaesthetic, or sedation. I was able to participate fully in both the anaesthetic side and the surgical side of operations. On the anaesthetic side, I was taught how to do an ankle block and then performed it for a man who was having a toe amputation. On the surgical side, I assisted with multiple c-sections, BTLs, and debridements. I learnt a lot from my time in theatres. First, from a medical point of view, I found myself relearning anatomy and now have a comprehensive understanding of the nerves and compartments of the lower limb. Second, in terms of clinical skills, the main learning was suturing. I went from having never sutured on a live person, to learning how to close the skin with mattress sutures and hand tie around bleeding vessels. Finally, and more broadly, I was left with a real appreciation for the value of preventative healthcare, as many of our patients were presenting with foot infections as a result of poorly controlled type 2 diabetes. With better access to medications and screening, many of these people would never have needed to be in hospital.

And also that a medical student on elective with limited evening entertainment may read a lot of Jane Austen.

The hidden costs of care, similar to the UK, were mostly surrounding travel and having to take time off work. Any referral to the capital (needed for any investigations more complex than an ultrasound) required a stay of at least a week as the boat only travels once a week – and that is when it isn’t cancelled for bad weather. Even if patients were not referred to the capital, just attending the provincial hospital at Gizo required expensive boat trips. I treated one boy for Yaws who needed daily dressings. With his family unable to afford daily travel, I instead provided his grandma with gauze and strict instructions to use cooled boiled water for any cleaning of it. While these barriers to accessing care felt familiar in kind to the UK, they felt much more extreme in degree.

The Solomons Islands have greater levels of poverty and lower levels of government support for ill health. However, one difference in terms of the cost of healthcare was that all prescriptions in the Solomon Islands are free, so a lot of paracetamol was prescribed!

The culture in the Solomon Islands is different to that in the UK. A first big cultural difference was that patients were much more patient in the Solomon Islands.

There were no appointments, instead patients would arrive at OPD and then be seen in the order in which they arrived. People were very happy to wait to be seen, with no sense of frustration. After being seen by me, they would often then have further waits: for malaria test results, scans, or to be seen by the doctors in their afternoon clinics. None of these waits appeared to engender any sense of frustration at any of the staff, quite different from ED or GP in the UK. A second big difference in culture was surrounding ideas of consent. In the Solomons Islands, all gynaecological operations required the consent of both the woman and her husband. Raised in a culture that prizes bodily autonomy, this really shocked me, and opened my eyes to the different rights had by women across the world.

The best part of the experience: responsibility and football

The best part of my elective was my final day in OPD. With one nurse away in the capital with her sick child, another off sick, and another not yet arrived, we were very short staffed. I was left to see all the patients in OPD for the morning, with the only nurse present covering ED itself. It was the best part of my elective for two reasons. First, the fact that I was able to confidently manage all of the patients that presented to OPD showed me just how much I’d learnt. Second, it allowed me to
give back something to a group of people who had been unfailingly welcoming and friendly to me. By being able to see all the patients who needed seeing, I was able to be a genuine help to the hospital. I had gained so much from my time there, that
I was grateful to be able to give even a little bit back.

As someone who is not a football fan, I did not expect to be saying that the best part of my elective was the football world cup. However, here I am. Everyone in the Solomon Islands was utterly obsessed with the World Cup, with everyone having a team which they passionately supported. Reasons for supporting a team were either “I like Messi/Ronaldo/etc.” (for the better teams) or “they built us a hospital” (for Japan). All of the cars in the town were flying flags, and one even had the Argentina flag painted on to the bonnet. Multiple patients greeted me with the question “who is your world cup team?”, with one England fan then incredibly excited that I actually came from that country. We even delayed an elective operation by 15 minutes so we could watch Paraguay stun Germany on penalties! The passionate enthusiasm was such fun to be a part of.

The worst part: the realities of healthcare

The worst part of my elective was undoubtably the sadness that came from seeing a child die who would likely have lived somewhere else. During my time in Gizo I was part of three such cases. A 9-year-old girl died of meningitis lying on an ED couch. With no intensive care and limited medications, there was nothing we could do for her as she deteriorated.

A baby girl was born stillborn, with the mother transferred in for a c-section too late from another hospital that lacked operating capacity. Another baby died following failed resuscitation attempts as there was not enough oxygen in the hospital to give to both this baby and another sick neonate. All three of these children were very unwell, and may not have survived in a higher resourced setting. But they might have done. They would certainly have had a better chance.

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